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Operation Guardians Reports

Evergreen Healthcare Centers of Vallejo - Springs Road (aka. Springs Road Healthcare) – Vallejo


The entire facility is filthy and in need of serious cleaning, including: patient rooms, showering room, food preparation, and supply rooms. The tiles surrounding one of the bathtubs eroded off the walls. Instead of a door, hanging plastic strips are used to separate the kitchen from outside making it easy for insects to enter and contaminate the area.

One resident was found lying on top of a diaper filled with dried feces. Seventy percent of the facility’s residents did not receive their ordered skin checks, pressure ulcer treatments, and other physician ordered treatments.

The facility is not in compliance with the state-mandate requiring a minimum of 3.2 hours of nursing care per resident per day. A vial inside the medication refrigerator was left open and undated. Several resident rooms lack call lights, or the call lights were on the floor away from the patients’ reach.